Executive Editor: Steve Krikler

Authors: Paulo Barbosa, Felix Bonnaire, Kodi Kojima

Malleoli Infrasyndesmotic, lateral isolated fracture

back to skeleton

Glossary

General considerations

These injuries usually do well without operative fixation. Immobilization is mainly for patient comfort, and early return to activity should be encouraged. 

Functional treatment
Indication summary Skill Equipment
Minimally displaced fractures, patients not fit for surgery, soft-tissue compromise, nonambulant patient Basic surgical experience, no specialized skills Basic equipment only

Indications

  • Minimally displaced, stable fractures
  • Patient not fit for surgery
  • Poor soft-tissue condition (excessive swelling, diabetes, neurovascular diseases)

Contraindications

  • Unstable fractures 
  • Severe soft-tissue injury 
  • Very displaced fracture with soft-tissue irritation

Advantages

  • Early functional recovery 
  • Patient comfort 
  • Full weight bearing possible if combined with a brace

Disadvantages

  • Only partial weight bearing allowed if not combined with a brace
Circular cast
Indication summary Skill Equipment
Minimally displaced fractures, patients not fit for surgery, soft-tissue compromise, nonambulant patient Basic surgical experience, no specialized skills Basic equipment only

Indications

  • Undisplaced, stable fractures 
  • Patient not fit for surgery
  • Poor soft-tissue condition (excessive swelling, diabetes, neurovascular diseases)

Contraindications

  • Dislocated or unstable joint
  • Severe soft-tissue injury 
  • Very displaced fracture with soft-tissue irritation

Advantages

  • Full weight bearing possible
  • Good stability

Disadvantages

  • Risks of cast complications (eg, pressure ulcer, nerve compression) 
  • Risks of immobilization (joint stiffness, muscle wasting)
  • Longer rehabilitation period
Tension band wiring
Indication summary Skill Equipment
Higher demand patient, small distal fragment Some specialized surgical experience Simple surgical and imaging resources

In isolated infrasyndesmotic transverse fractures of the lateral malleolus fractures, because the lateral malleolar fragment includes the articular surface which articulates with the lateral aspect of the talus, there is an argument in favor of fixation.
Through an open approach, inspection and lavage of the joint can be performed and any loose osteochondral fragments removed.

Indications

  • Distal fragment too small for plating
  • Displaced, unstable fractures 
  • Loss of reduction after nonoperative treatment 
  • High demand lifestyle (sport, heavy labor, etc.)

Contraindications

  • Patient not fit for surgery
  • Poor soft-tissue condition (excessive swelling, diabetes, neurovascular diseases) 
  • Functionally low demand patient

Advantages

  • Less dissection and less expensive compared to plating
  • Anatomical reduction of the joint 
  • Stable fixation 
  • Early functional recovery 
  • Good long-term results

Disadvantages 

  • Soft tissue irritation 
  • Risk of backing out of the K-wires 
  • Wire breakage with poor twisting technique
  • Cosmetic appearance 
  • Surgical risks
Tension band plate
Indication summary Skill Equipment
Higher demand patient; large distal fragment Some specialized surgical experience Simple surgical and imaging resources

In isolated infrasyndesmotic transverse fractures of the lateral malleolus, because the lateral malleolar fragment includes the articular surface which articulates with the lateral aspect of the talus, there is an argument in favor of fixation.
Through an open approach, inspection and lavage of the joint can be performed and any loose osteochondral fragments removed.

Indications

  • Large distal fragment
  • Displaced, unstable fractures
  • Loss of reduction after nonoperative treatment 
  • High demand lifestyle (sport, heavy labor, etc.)

Contraindications

  • Patient not fit for surgery
  • Poor soft-tissue condition (excessive swelling, diabetes, neurovascular diseases) 
  • Functionally low demand patient

Advantages

  • Absolute stability
  • Better rotational control than in tension band wiring
  • Anatomical reduction of the joint 
  • Early functional recovery
  • Good long-term results

Disadvantages

  • Needs more dissection
  • Risk of skin breakdown 
  • Skin irritation through bulky implant 
  • Risk of intraarticular penetration by screw tip
  • Cosmetic appearance 
  • Surgical risks
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2015-12-04